Tag Archives: medication adherence

Last week my office received a call from a distressed patient who went to the pharmacy to fill prescriptions following a hospitalization. The cost for a month’s worth of three medications she was expected to stay on indefinitely was over $800. With mortgage rates being what they are, most people don’t have mortgage payments that big. She called our office in a panic. As she related her story, I wondered how this fiasco could have been avoided. When I prescribe medications, either my EHR or my Epocrates program gives me an idea of what the patient’s price will be based on her insurance. Is that too difficult for hospitalists to do? That sounds sarcastic, but I’m serious. Are the logistics for a hospitalist such that running medication through software to determine the likelihood a patient can afford them not realistic? What about the pharmacists in the hospital? Could this become part of the discharge process? Patients should not have to deal with “sticker shock” after a difficult hospitalization.

I changed two of her meds to inexpensive generics and called a cardiologist to ask what to do with the anti-arrhythmic. He told me that the new medication was only slightly better than placebo in studies. And for that she was paying over $300/month!

One of the Affordable Care Act provisions is that hospitals will be penalized for readmissions within a month of discharge. It will become incumbent on the hospital team to have a better understanding of medication costs, one of many reasons why patients are non-adherent[1] with their therapy. As the family physician getting panicked phone calls I view this as a good thing. My patients will be discharged on medications they can afford and will take. Then we can spend our time in the office taking care of health problems instead of fixing something that shouldn’t have been broken to begin with.

Recently a patient in our practice requested his Plavix renewal from a 90-day mail order pharmacy. When the “estimated” price came to $585 he decided to stop taking his cardiac medication. In exploring his insurance website I found that the actual cost would only be $200. In addition the company had a “Do Not Substitute” order on the prescription (something his cardiologist denies writing) and the cost of the generic is $28.59. Wow–the drug he almost quit taking because of the website price estimation was, in reality, 96% cheaper than originally thought.

Contrast this with a phone call I received recently from Wish’s Drugs, a local pharmacy here in Louisville. The pharmacist paged me on a Saturday morning regarding a patient’s medication. I called the pharmacy and the pharmacist answered the phone(!). He suggested that my patient get a similar drug for half the cost of what I prescribed and asked if that would be OK. When I hung up the phone it struck me how pleasant that had been. Not just that the pharmacist was looking out for the interest of our mutual patient, but the call from start to finish–a real person answered the phone and it was the person I needed to speak to. Not only did I not push three different buttons and listen to three different voice messages along with a sales pitch for flu shots, but I immediately spoke to a person knowledgable and caring about my patient and her medical condition. Contrast THAT with the 90 day site where the patient, unknowing, was supposed to go back to his insurance web site, check the price of his medication and THEN go back to the pharmacy web site and decide that he could actually afford the medication because the real price to him would (only) be $200. No friendly pharmacist in that other state willing to make a phone call and get his patient a better deal on his medicine.

It’s not that I think mail order pharmacies are inherently evil, it’s just that the service component is reduced to the patient. However, interestingly enough, the two studies I read regarding mail-order vs. local pharmacies [1,2] found patients are more compliant when they use mail order. Perhaps this is because when medicines are delivered right to the patient’s door it reduces extra steps, making it easier for patients to remember and obtain their drugs?

In my experience patients enjoy the convenience and economy of getting 90 days worth of medication delivered to their mailbox but when there is a problem they are quickly frustrated by the difficulty of explaining to someone in another state what their needs are. As a physician, I am annoyed with the same difficulties, plus the frequent faxes asking about changing patients to a “cost-savings” alternative, something the patient is usually unaware of so we have to call him/her, ask their permission, explain what the change entails, etc. Just one more thing in my over-extended day that I don’t have time for.

Mail order pharmacies are not going away and local pharmacies where the pharmacist knows the patient and cares for him/her in a more intimate way are disappearing into distant, nostalgic memories. Given the studies quoted here, maybe that’s a good thing. Does my desire for it to be different, for every patient to have the individual attention of the good pharmacist at Wish’s make me out-dated? 1. Schmittdiel JA. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.J Gen Intern Med. 2011 Dec;26(12):1396-402. Epub 2011 Jul 20 2. Duru OK. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010 Jan;16(1):33-40